As a psychiatrist who frequently encounters patients struggling with Borderline Personality Disorder (BPD), the concept of intolerance of aloneness often comes up during therapy. This inability to be alone is not merely about a dislike for solitude; it is a core psychological deficit that greatly affects the lives of individuals with BPD. Recently, I was reminded of this concept, articulated by Dr. John G. Gunderson in his 1996 paper, The Borderline Patient’s Intolerance of Aloneness. After seeing patients exhibit similar struggles, I decided to revisit this work and share its clinical significance.

Understanding the Intolerance of Aloneness

At the heart of Gunderson’s work is the idea that people with BPD experience an overwhelming fear of abandonment and cannot tolerate being alone. This fear can lead to impulsive behaviors, emotional instability, and intense efforts to avoid perceived rejection. Gunderson argues that this intolerance stems from early childhood experiences where these individuals did not develop a stable sense of security with their caregivers.

Gunderson explains that for individuals with BPD, their early attachment to caregivers was often inconsistent or absent, preventing them from developing what psychoanalysts call a “soothing introject.” A soothing introject refers to an internalized sense of comfort and security, where the individual can recall the presence of a caring figure even when physically alone. Without this internalized sense of security, the individual constantly seeks external reassurance to feel safe, leading to the intense need for the presence of others.

The Impact of Insecure Attachments

Gunderson connects the intolerance of aloneness to insecure attachment patterns. Drawing on John Bowlby’s attachment theory, he highlights how early relationships shape an individual’s ability to form secure bonds later in life. Bowlby believed that infants are biologically wired to seek proximity to a caregiver, and the consistency of this caregiver is essential for the child’s emotional development.

For individuals with BPD, these early attachment bonds were likely inconsistent or even traumatic. Gunderson describes how individuals with BPD often oscillate between clinging to others and pushing them away, reflecting the anxious-ambivalent attachment pattern described by attachment theorist Mary Ainsworth. This constant fear of being abandoned or rejected fuels the emotional instability seen in BPD patients.

Aloneness and Maladaptive Behaviors

One of the key points that Gunderson makes is how the intolerance of aloneness manifests in maladaptive behaviors. When individuals with BPD feel abandoned or alone, they often engage in self-destructive behaviors as a way to cope with the overwhelming anxiety. These behaviors can range from impulsivity to self-harm, and even to suicidal threats. The goal is often to draw attention or reassurance from others, even if the actions are harmful.

This concept is also reflected in the DSM-5 criteria for Borderline Personality Disorder, where fear of abandonment, impulsive behaviors, and emotional instability are key diagnostic features.

How Can Therapists Help?

One of the challenges of treating individuals with BPD is how to manage their fear of aloneness in the therapeutic setting. Gunderson emphasizes the importance of the therapist’s availability. Patients with BPD often require reassurance that their therapist will be available to them during times of crisis, but Gunderson warns that offering too much availability can create dependency and prevent the patient from developing a sense of internal security.

Therapists should aim to strike a balance between being reliable and consistent without encouraging regression. Gunderson suggests that therapists should be available for genuine emergencies but must also encourage patients to develop coping strategies that allow them to manage their feelings of aloneness more independently.

By fostering a stable therapeutic relationship, therapists can help individuals with BPD begin to internalize a sense of security and gradually build the capacity to tolerate being alone. This process is long and challenging, but over time, patients can develop healthier ways to manage their emotions without relying solely on external validation.

Revisiting Gunderson’s Ideas in Modern Practice

As I reflect on Gunderson’s work and apply it to my practice, it becomes clear that the fear of being alone is a core issue for many of my patients with BPD. Addressing this fear requires not only therapeutic patience but also a deep understanding of the attachment wounds that underlie the disorder.

By helping patients recognize their fear of aloneness and teaching them to self-soothe, therapists can offer a path towards emotional stability and independence. The goal is not to eliminate relationships or connection but to help the individual develop an inner sense of security that allows them to function without constantly seeking reassurance from others.

Conclusion

John G. Gunderson’s work on the intolerance of aloneness in BPD remains an essential contribution to our understanding of this complex disorder. His insights into how early attachment failures contribute to emotional instability and the fear of abandonment provide a framework for effective therapeutic intervention. For therapists, finding the right balance of availability while encouraging emotional independence is crucial in helping patients develop the capacity to be alone without falling into despair or self-destructive behaviors.

In revisiting Gunderson’s work, I am reminded that the path to healing for patients with BPD involves both compassion and structure. By offering consistent care and helping patients internalize a sense of safety, we can guide them towards a healthier relationship with both themselves and others.